ED Coding and Reimbursement Alert

Question: We used to report modifier 59 (Distinct procedural service) frequently, but our administrator said we should use it sparingly, as it’s the “modifier of last resort.” Now we don’t use it at all, but I think we should be. When is this modifier warranted in the ED?

Texas Subscriber

Answer: You’re correct that modifier 59 should only be used when no other modifier is appropriate, but you’re also correct that there are some instances when it’s the only modifier that will describe your situation, and in those cases, it must be used.

For example, you’ll use modifier 59 when procedures which are not ordinarily performed or encountered on the same day are performed on different organs or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

For instance, a patient presents with a laceration of the proximal finger by the MCP joint and a noncontiguous nail bed injury on the same finger. As these are two distinct injuries and not connected, appending modifier 59 would be appropriate to indicate separate noncontiguous procedures. You’d report these services as follows:

• 11760 (Repair of nail bed)
• 12001-59 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less)

Keep in mind, if a more specific modifier is available, you should use it. For instance, a repeat EKG by the same physician would require modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) on the second procedure code, not modifier 59.